Tibial pin placement

Drilling a hole in the thick tibial crest may be associated with excessive heat generation and there is a risk the drill bit may slip medially or laterally damaging the soft tissues. As the anteromedial tibial wall provides adequate thickness for the placement of pins, this trajectory is preferable. A trajectory angle (relative to the sagittal plane) of 20-60° for the proximal fragment and of 30-90° for the distal fragment is recommended.

Alternatively, in order to avoid the frame catching on the opposite leg, the pins may be placed more anteriorly. The drill bit is started with the tip just medial to the anterior crest, and with the drill bit perpendicular to the anteromedial surface (A). As the drill bit starts to penetrate the surface, the drill is gradually moved more anteriorly until the drill bit is in the desired plane (B). This should prevent the tip from sliding down the medial or lateral surface.

Reduction and fixation

Plating of the fibula

Pearl: Prevent plantar flexion contracture

In patients with severe soft-tissue involvement, it may be helpful to add a pin in the foot (one of the tarsal or metatarsal bones) to maintain the ankle at a 90° angle and prevent a plantar flexion contracture.

The pin may be inserted in either the navicular bone, in one of the cuneiforms, in the first metatarsal base, or in the first and fifth metatarsal base, and connected with a rod to the tibial external fixator. Care should be taken to insert the pin bicortically and to avoid the intra-articular spaces.